Action Points

Different treatment options for localized prostate cancer led to different profiles for patient-reported outcomes (PRO) and quality-of-life. Specifically, radical prostatectomy was associated with greater declines in sexual function and worse urinary incontinence as compared with external beam-radiation therapy (EBRT) or active surveillance after 1 year of follow-up, and worsening sexual function and urinary continence was seen at 3 months with surgery or radiation therapy, but by 24 months of follow-up, scores on PROs did not differ significantly by treatment choice.

Note that combined with results of previous research, data from the two prospective cohort studies informed three issues that patients with localized prostate cancer should consider when selecting an option for initial treatment.

Different treatment options for localized prostate cancer led to different profiles for patient-reported outcomes (PROs) and quality-of-life (QOL), according to two large prospective cohort studies.

The larger of the two studies showed that radical prostatectomy was associated with greater declines in sexual function and worse urinary incontinence as compared with external beam-radiation therapy (EBRT) or active surveillance after 1 year of follow-up. The second study showed worsening sexual function and urinary continence at 3 months with surgery or radiation therapy, but by 24 months of follow-up, scores on PROs did not differ significantly by treatment choice, as reported in JAMA.

Combined with results of another recent study, data from the two prospective cohort studies informed three issues that patients with localized prostate cancer should consider when selecting an option for initial treatment.

"First, each man can take time to assess carefully with his treating physician the risk of receiving treatment or active surveillance, taking into account the tumor risk category and his general health," Freddie C. Hamdy, MD, of the University of Oxford, and Jenny L. Donovan, PhD, of the University of Bristol, both in England, said in an accompanying editorial. "Second, each treatment has a particular pattern of adverse effects on quality of life in the short term ... "

"Third, even though with active surveillance, adverse effects of interventions can be avoided initially, there is a natural decline in urinary and sexual function symptoms over time, and the adverse effects of radical treatments will be experienced when those treatment are received."

Men with localized prostate cancer "have never been better informed" about the trade-offs associated with different treatment options, Hamdy and Donovan added. Longer-term follow-up data from the earlier trial will further inform discussions about treatment options.

The data showed that 1,523 men underwent radical prostatectomy, 598 opted for EBRT, and 429 entered active surveillance. Men treated with EBRT were older (68.1 versus 61.5, P<0.001) and had worse sexual function (P<0.001) as compared with the surgically treated group.

At 3 years, the prostatectomy group had a larger decline in sexual domain score compared with the EBRT group (mean difference -11.9 points, 95% CI -15.1 to -8.7), whereas the EBRT domain score did not decline significantly versus the active surveillance group (-4.3 points, 95% CI -9.2 to +0.7). Radical prostatectomy was associated with worse urinary incontinence as compared with EBRT (-18.0, 95% CI -20.5 to -15.4) and active surveillance (-12.7, 95% CI -16.0 to -9.3).

Prostatectomy was associated with better urinary irritative symptoms compared with active surveillance (5.2, 95% CI 3.2-7.2). The three groups did not differ significantly with respect to bowel or hormone function after 12 months. Health-related QOL and disease-specific survival (99.7% to 100%) also did not differ across the groups.

The second study involved 1,141 men with clinically localized prostate cancer enrolled in the North Carolina Central Cancer Registry from January 2011 through June 2013 within 5 weeks of prostate cancer diagnosis, reported Ronald Chen, MD, of the University of North Carolina in Chapel Hill, and colleagues.

The men were evaluated by means of the Prostate Cancer Symptom Indices, which encompass four domains: sexual dysfunction, urinary obstruction/irritation, urinary incontinence, and bowel problems. Each domain had a score range of 0 (no dysfunction) to 100 (maximum dysfunction). After a baseline assessment of QOL, follow-up assessments occurred at 3, 12, and 24 months after treatment.

The study population comprised 314 men who entered active surveillance, 469 who underwent radical prostatectomy, 249 who opted for EBRT, and 109 treated with brachytherapy. After propensity weighting, the men in the treatment groups had a median age of 66 to 67 and baseline scores of 41.8 to 46.4 for sexual function, 20.8 to 22.8 for urinary obstruction/irritation, 9.7 to 10.5 for urinary incontinence, and 5.7 to 6.1 for bowel problems.

The study by Barocas' group was supported by the AGency for Healthcare Research and Quality, National Cancer Institute, and Patient-Centered Outcomes Research Institute. Barocas disclosed no relevant relationships with industry. One or more co-authors disclosed relationships with Myriad Genetics, Genomic Health, Genome Dx, Dendreon, Astellas, Bayer, Janssen, Urology Care Foundation, and MDx Health.

The study by Chen's group was supported by the Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, the Integrated Cancer Information and Surveillance System, and the University of North Carolina.

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